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NurseDive Free Nursing Practice Question
A nurse is admitting a client who has a serum calcium level of 12.3 mg/dL and initiates cardiac monitoring. Which of the following findings should the nurse expect during the initial assessment?
A. Prolonged ST segment
B. Hyperactive bowel sounds
C. Lethargy
Hypercalcemia can lead to central nervous system depression, resulting in lethargy, confusion, and a decreased level of consciousness. Prolonged ST segment is not a specific finding related to hypercalcemia. Instead, shortened QT intervals may be seen. Hyperactive bowel sounds are not typically associated with hypercalcemia. Instead, constipation or ileus may occur. Hyperactive deep tendon reflexes are not typically associated with hypercalcemia
D. Hyperactive deep tendon reflexes
This question is an excerpt from Nurse Dive's nursing test bank - ATI Med surg exam 1A Proctored Exam. Take the full exam now
Similar Questions
A nurse is preparing to administer Ringer's lactate 500 mL IV bolus to infuse over 3 hr. The drop factor of the manual IV tubing is 20 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Full Explanation
To calculate the infusion rate in gtt/min, we need to know the total number of drops (gtt) needed
for the entire infusion and the time it takes to complete the infusion. Given:
- Ringer's lactate: 500 mL
- Infusion time: 3 hours
- Drop factor: 20 gtt/mL
First, let's calculate the total number of drops needed for the entire infusion: Total drops = Volume (mL) × Drop factor (gtt/mL)
Total drops = 500 mL × 20 gtt/mL Total drops = 10,000 gtt
Next, we need to determine the infusion rate in gtt/min. Since the infusion time is given in hours, we need to convert it to minutes:
Infusion time (min) = Infusion time (hours) × 60 min/hour Infusion time (min) = 3 hours × 60 min/hour
Infusion time (min) = 180 min
Now, we can calculate the infusion rate in gtt/min:
Infusion rate (gtt/min) = Total drops / Infusion time (min) Infusion rate (gtt/min) = 10,000 gtt / 180 min
Infusion rate (gtt/min) ≈ 55.6 gtt/min (Rounded off- 56 gtt/min)
A nurse is assessing a client who is at the end of life. Which of the following findings should the nurse expect?
A. Hypertension
B. Tachycardia
C. Moist mucous membranes
D. Irregular respirations
As the body approaches the end of life, the respiratory pattern often becomes irregular and may include periods of apnea or shallow breathing. Hypertension is not a common finding at the end of life. Instead, blood pressure tends to decrease as the body's systems begin to shut down. Tachycardia (rapid heart rate) is not a typical finding at the end of life. Instead, the heart rate may slow down as the body's functions decline. Moist mucous membranes are not specific to the end of life. They can vary based on various factors such as hydration status and medical conditions.
A nurse is preparing to administer potassium chloride (KCL) to a client who is receiving diuretic therapy. The nurse reviews the client's serum potassium level results and discovers the client's potassium level is 3.2 mEq/L. Which of the following actions should the nurse take?
A. Hold the prescribed dose and notify the provider of the serum potassium level.
This action would be appropriate if the potassium level were high, indicating hyperkalemia. However, since the client's potassium level is low, the nurse should administer the KCl as prescribed to address the hypokalemia. If there are any concerns about the rate or method of administration, or if the client shows signs of potassium-related complications, the nurse should then consult the provider.
B. Call the lab to verify the client's results.
Calling the lab to verify the client's results may seem like a reasonable action, but it's not the most appropriate in this scenario. Serum potassium levels are commonly measured accurately, and the nurse should prioritize clinical judgment based on the current potassium level in conjunction with the client's condition and medication regimen.
C. Give the ordered KCL as prescribed.
A serum potassium level of 3.2 mEq/L is below the normal range (3.5-5.0 mEq/L), indicating hypokalemia. Hypokalemia can have serious consequences, including muscle weakness, cardiac arrhythmias, and other complications. Administering potassium chloride (KCl) as prescribed is necessary to correct this deficiency and prevent potential adverse effects associated with low potassium levels.
D. Omit the KCL dose and document that it was not given.
Simply omitting the KCL dose without informing the healthcare provider of the client's low potassium level could lead to a missed opportunity for appropriate intervention. Documenting the omission is essential for accurate record-keeping, but it's crucial to communicate the situation to the provider for further guidance.
Full Explanation
Correct answer: C
A. This action would be appropriate if the potassium level were high, indicating hyperkalemia. However, since the client's potassium level is low, the nurse should administer the KCl as prescribed to address the hypokalemia. If there are any concerns about the rate or method of administration, or if the client shows signs of potassium-related complications, the nurse should then consult the provider.
B. Calling the lab to verify the client's results may seem like a reasonable action, but it's not the most appropriate in this scenario. Serum potassium levels are commonly measured accurately, and the nurse should prioritize clinical judgment based on the current potassium level in conjunction with the client's condition and medication regimen.
C. A serum potassium level of 3.2 mEq/L is below the normal range (3.5-5.0 mEq/L), indicating hypokalemia. Hypokalemia can have serious consequences, including muscle weakness, cardiac arrhythmias, and other complications. Administering potassium chloride (KCl) as prescribed is necessary to correct this deficiency and prevent potential adverse effects associated with low potassium levels.
D. Simply omitting the KCL dose without informing the healthcare provider of the client's low potassium level could lead to a missed opportunity for appropriate intervention. Documenting the omission is essential for accurate record-keeping, but it's crucial to communicate the situation to the provider for further guidance.